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2. This report is designed to assist Maricopa County in determining what areas have experienced structural flooding and damage due to severe weather. This report will allow damage assessment teams to quickly assess the area. Your information will not be shared with anyone outside of government.

   Please DO NOT use this survey to request direct assistance or disaster relief. Relief agencies are listed at www.maricopa.gov/gilabendrecovery. As always, for emergency assistance, dial 9-1-1.

   ONLY Enter information regarding Gila Bend flooding, August 2021.

4. Personal Information
6. Last Name:
7. First Name:
8. Middle Initial:
10. Address:
11. Apartment:
13. City:
14. State:
15. Zip:
17. Home Phone:
18. Home Phone Details:

    1. Text Capable
20. Work Phone:
21. Work Phone Details:

    1. Text Capable
23. Cell Phone:
24. Cell Phone Details:

    1. Text Capable
26. Damage and Needs
28. Structural Damage to Home, 50% Greater?

    1. Yes
29. Damage Definitions

    See damage definitions at bottom of form.

31. Homeowners Insurance?

    1. Yes
32. Flood Insurance?

    1. Yes
33. Content (renters) Insurance?

    1. Yes
35. Description of Damage
37. Estimated Dollar Amount of loss

    (include construction and content costs)

38. Estimated Property Value (Home and Land)
40. Flood Water Damage?

    1. Bedroom
    2. Kitchen
41. Utilities Running?

    1. Water
    2. Gas
    3. Electric
42. How high did water get in home?

    (inches)

44. Additional Damage Information:
46. Damage Definitions

    Destroyed - structure is a total loss or damaged to such an extent that repairs are not economically feasible. Any one of the following may constitute a status of destroyed:

    •   Repair of structure is not economically feasible;
    •   Structure is permanently uninhabitable;
    •   There is a complete failure of major structural components (collapse of walls or roof); or
    •   Unaffected structure will be required to be removed or demolished due to ordinance (e.g., beachfront homes removed due to severe beach erosion)

    Major - structure has sustained structural or significant damage, is uninhabitable and requires extensive repairs. Any of the following may constitute major damage:

    •   Substantial failures to structural elements of the residence (e.g., walls, floors, foundations);
    •   Damage to the structure exceeds the Disaster Housing Program, Home Repair Grant maximum ($10,000);
    •   General exterior property damage exceeds the Disaster Housing Program Home Repair Grant maximum (e.g., roads and bridges, wells, earth movement) and has more than 50% damage to the structure; or
    •   Damage will take more than 30 days to repair.

    Minor - structure is damaged and uninhabitable but may be made habitable in a short period of time with home repairs. Any of the following may constitute minor damage:

    •   Structure can be repaired within 30 days;
    •   Structure has more than $100 of eligible habitability items through the Disaster Housing Program, Home Repair Grant; has less than $10,000 of eligible habitability items through the Disaster Repair Program, Home Repair Grant; or
    •   Damage repair costs are less that 50% of total value of hous.

    Affected - structures sustain some damage to structure and contents but which are habitable without repairs and damage to habitability items is less than Disaster Housing Program, Home Repair Grant minimum.

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48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit Submit and Print

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